TNF and pemphigus vulgaris: It has been proposed that local trauma induces a pro-inflammatory milieu, triggering keratinocyte proliferation and epidermal hyperplasia through cytokine-mediated signaling (e.g., IL-1α, TNF-α) and oxidative stress [2,7,8]. In this patient, who has a history of pemphigus vulgaris, a condition itself known to exhibit koebnerization, an underlying predisposition to isomorphic responses may have been a contributing factor [3,7].